Annals of Emergency Medicine
Geriatric Savvy
The nation’s emergency departments have begun to ramp up efforts to better address the needs of older individuals, from adding geriatric-friendly equipment to specialized staff to more routine screening for delirium, dementia, and fall risk. (2018)
(Direct link to the article here.)
By Charlotte Huff
Kevin Biese, MD, said he trained for “helicopters and chest tubes” as he was wrapping up his residency about a dozen years ago. But his shifts as an emergency physician at the University of North Carolina at Chapel Hill are more likely to unfold far differently these days, with home health referrals, delirium assessments, fall-related concerns, and end-of-life treatment quandaries.
The nation’s emergency departments (EDs) operate more like a “care transitions hub,” Dr. Biese said. “We are no longer just acute accidents and injuries. But rather we’re the place you go to decide what the diagnosis is, and what the care plan is after that.”
As chair, Dr. Biese is leading the American College of Emergency Physicians’ (ACEP’s) board of governors for its geriatric ED accreditation initiative, a just-launched effort to improve and standardize emergency care of the nation’s older patients. Approximately 60% of Medicare patients who are admitted to the hospital arrived first through the ED, according to a RAND Corporation report published in 2013.
Research published in recent years also has highlighted how older adults, defined as aged 65 years and older, frequently struggle more medically and physically after an emergency visit, even if they were never admitted to the hospital.
One study, published 2017 in Annals of Emergency Medicine, compared 2 groups of older adults—one group had visited the ED and the second had not. Older patients who went to the ED, even though they weren’t hospitalized, scored an average of 14% higher on a disability scale during the subsequent 6 months compared with those who had not.
Another study, published in 2016 in the American Journal of Medicine, found an average 6-point decline on a mobility assessment scale after an ED discharge, beginning the first month and extending through the first year.
The underlying causes are not clear, but that loss of mobility could have a practical effect, said Cynthia Brown, MD, lead author of the American Journal of Medicine study who directs the division of gerontology, geriatrics, and palliative care at the University of Alabama at Birmingham. As an illustration, Dr. Brown described one man who had previously relied on his walker only outside the home, and started using it to get around inside as well, she said. “Why is that happening?” she said. “It is not what I expected.”
The geriatric ED accreditation process, which begins this year, follows a series of related efforts. In 2013, ACEP and several other medical groups released geriatric ED guidelines, recommending measures ranging from adding geriatric-friendly equipment to specialized staff to more routine screening for delirium, dementia, and fall risk, among other vulnerabilities. Dr. Biese also serves as the coprincipal investigator of a 9-health-system research collaborative—launched in 2016 and involving the same medical groups, including ACEP—that are working together to develop and share ways to improve care.
The voluntary geriatric ED accreditation, which includes 3 levels similar to trauma designations, will provide specific criteria and goals for emergency clinicians and administrators to target, Dr. Biese said. Once they achieve accreditation, EDs can market their geriatric expertise to local patients, he said. Plus, better care of older adults, including steps to assist their safe return home, can reap financial benefits in a reimbursement environment in which hospitals can be penalized for readmissions and other poor outcomes, he said.
Regardless, older adults will continue to arrive through the ED’s doors, and in increasing volumes. The first cadre of baby boomers reached aged 65 years in 2011. By 2029, the entire demographic group will be aged 65 years or older, according to US Census Bureau data.
“Our role in the health care system is changing,” Dr. Biese said. “We can either drive this bus or get dragged by it.”
Addressing Multineeds
For older patients, an emergency visit can present both a critical crossroads and an opportunity, said Ula Hwang, MD, MPH, who chairs ACEP’s geriatric emergency medicine section. Patients are frequently sent there because they have a mix of medical conditions, or related uncertainties, that can’t be addressed in an evaluation through a physician’s office, said Dr. Hwang, an associate professor of emergency medicine, geriatrics, and palliative medicine at Icahn School of Medicine at Mount Sinai.
During that visit, clinicians have the opportunity to flag other risk factors, whether it’s a potential for falls or a risky combination of medication, Dr. Hwang said. But EDs are instead typically structured with an eye toward handling acute conditions with a primary focus on “rapid assessment, evaluation, triage,” she said.
Although Dr. Brown said that her study strived to adjust for the higher medical acuity of older adults seeking emergency care, she acknowledged that it might still play a role in less mobility once they return home. Perhaps there’s a self-limiting psychosocial influence as well, she said. “You think, ‘Well, gee, I had to go to the emergency room, so maybe I need to not be out and about as much.’”
Other recent data, involving 3 urban hospitals using geriatric-focused interventions in 2013 to 2015, found that just one component—the addition of a transitional care clinician—reduced the likelihood that the ED patient would be hospitalized, according to data published online in early 2018 in the Journal of the American Geriatrics Society. The transitional care clinician, who was a registered nurse or a nurse practitioner consulted with approximately 10% of the slightly more than 57,000 older patients treated at 1 of the 3 hospitals, allowing researchers to compare outcomes with a similar group of patients who didn’t get that support, said Dr. Hwang, lead author on the Journal of the American Geriatrics Society study.
The reduced likelihood of a hospital admission ranged from 4.72% at St. Joseph’s Regional Medical Center in Paterson, NJ, to 9.9% at New York City’s Mount Sinai Medical Center to 16.46% at Northwestern Memorial Hospital in Chicago. Naysayers, Dr. Hwang said, could question whether in some cases the patient was discharged inappropriately from the ED. But researchers also tracked any inpatient admission within 30 days of the ED visit, and it was lower as well among patients who consulted with a transitional care clinician: St. Joseph’s (-1.38%), Mount Sinai (-7.79%), and Northwestern Memorial (-13.82%). (The reductions at only the latter 2 hospitals reached statistical significance, she said.)
Now these 3 hospitals are part of the larger 9-health-system research collaborative, which was launched in 2016 with a $3 million grant from 2 nonprofit organizations, the John A. Hartford Foundation and the Gary and Mary West Health Institute. Three other medical groups, who also developed the geriatric ED guidelines with ACEP, are involved with the collaborative: the American Geriatrics Society, the Emergency Nurses Association, and the Society for Academic Emergency Medicine.
Incentivizing Expertise
In 2007, Dr. Hwang coauthored an article in the Journal of the American Geriatrics Society, proposing the need for more geriatrics expertise in the ED. At that time, she couldn’t locate any hospitals promoting such expertise, she said.
But in the years since, EDs have increasingly been developing and promoting their geriatric treatment savvy. A survey conducted in 2013, and published the following year in Academic Emergency Medicine, identified at least 3 dozen hospitals reporting a geriatric ED.
Drs. Biese and Hwang believe that figure is now much higher. In accordance with anecdotal reports and other efforts at an updated count, Dr. Biese estimates that approximately 100 US hospitals promote themselves as having geriatric EDs. “Part of the reason for ACEP to do this [accreditation] is our experience has been that the quality of care in those varies widely,” Dr. Biese said. By setting accreditation criteria, similar to the trauma designations, he said, “if you say that you’re a geriatric ED,” the public understands what that means.
The accreditation process provides more than 2 dozen best practices for geriatric care, and the level achieved depends on how many an ED strives to meet, along with some other components, Dr. Biese said. To move forward, emergency clinicians don’t have to designate a specific area or room for older patients, but rather should focus on building the necessary expertise and having more mobility-focused equipment on hand, among other steps, according to Dr. Biese.
To achieve the most basic level, called level 3, an ED will need to demonstrate that its staff includes both a physician and a nurse with some specialized geriatric training, according to Dr. Biese. Level 3 EDs also will have to meet a few environmental criteria, such as easy patient access to water and a few mobility aids such as 4-pronged walkers. Another key component is the implementation of a geriatric-focused quality improvement project. That’s essentially it, Dr. Biese said. “Some champions, a project, some basic equipment.”
By way of comparison, a level 1 ED will have to pursue the greatest number of best practices, along with tracking some related metrics, employing additional geriatric-trained staff, and investing in a broader spectrum of mobility aids.
ACEP’s accreditation process also will work with rural hospitals that want to boost their geriatric expertise within their own staffing and other limitations, Dr. Biese said. For instance, levels 1 and 2 stipulate that a transitional care nurse or nurse case manager focused on geriatric care be present at least 56 hours a week. But it may be that some of that coverage could be handled through telemedicine, he said.
Given that rural hospitals treat an even higher percentage of older adults than their urban counterparts, Dr. Biese said, “We’re not going to do a good job unless we figure out how to make this work well in rural America, and so we’re committed to that.”
Small Changes Benefit
Dwayne Dobschuetz, APRN, who worked as a transition care nurse until recently at Northwestern’s ED, said that even hospitals that don’t develop a geriatric ED can still provide a better bridge for older patients returning homes. Sometimes all that requires is taking the time to ask a few additional questions, said Mr. Dobschuetz, a geriatric nurse practitioner who now makes home visits for Northwestern.
Mr. Dobschuetz described one woman in her 90s who arrived at the ED after a fall. She hadn’t suffered any notable injuries, but during his assessment Mr. Dobschuetz learned that she lived in a basement apartment, with 7 steps down to reach her residence.
He walked with her to a nearby stairwell. She couldn’t manage even one step. “Normally, she would have been sent home because she was ambulatory,” Mr. Dobschuetz said. Instead, the elderly woman was admitted for a day or two of physical therapy until the steps weren’t so daunting.
To help avert that postdischarge mobility slide, emergency clinicians can encourage their older patients to return to their previous regimen of activities as soon as feasible, said Dr. Brown, the geriatrician at the University of Alabama at Birmingham. If the patient’s habit was to visit the shopping mall 3 times a week before the emergency visit, encourage him or her to shoot for that goal, she said.
As of late February, Dr. Biese was bullish on the level of ED interest in the accreditation process. Eight hospitals were already participating in the pilot and he predicted that at least 50 hospitals would be pursuing some level of accreditation by year’s end. He hopes that momentum will build as hospitals market their geriatric accreditation locally. “My opinion is that the market can be a good thing if it encourages folks, adds momentum to make care even better,” he said.
The clinicians and researchers who have pioneered the work in this area frequently use the term GEDI, the acronym for geriatric ED innovations. Mr. Dobschuetz pointed out that the term allows clinicians to request a consultation for “a GEDI” amid the ED swirl without bystanders realizing that they are referring to an older and likely more medically vulnerable patient.
Dr. Hwang said that she coined the acronym—pronounced “Jedi”—in her 2007 Journal of the American Geriatrics Society article. Her intention from the start, she said, was to convey the wisdom and power of older adults, such as the Jedis of Star Wars lore.